Sunday, October 1, 2017

The dramatic increase in
the prevalence of autism spectrum conditions among children over the past decade
indicates that a correspondingly large number of youth will be transitioning to adulthood in the coming years. It is estimated that more than 50,000
adolescents with autism will turn 18 years old this year in the U.S. As these numbers continue to rise, there is an
urgent need to address the mental health issues faced by many adults on the autism spectrum.

Although we know that
children with autism grow up to be adults with autism, there are fewer mental
health services available for adults on the spectrum, particularly for
individuals who are not intellectually challenged. A review in the open access journal,
Autism Research and
Treatment, highlights the service needs and the corresponding gaps in care
for this population. The authors posit that the mental health system is in
crisis and that although the rates of mental health issues for adults on the
spectrum is high, accessing services to address these symptoms remains
difficult. Poor recognition tends to occur for a number of different reasons,
including restrictive intake criteria, misdiagnosis, limited knowledge or
awareness of autism spectrum conditions, clinicians who lack confidence or
experience in caring for this group of adults, and the belief that other
service providers will provide this care. Consequently, many adolescents and
adults on the autism spectrum, because of their diagnosis, are excluded from
community mental health services, leaving them grossly underserved.

Mental Health Issues

Comorbid (co-occurring) psychiatric
disorders are well documented in individuals with autism across the lifespan.
Research suggests that a very high proportion of adults and teens on the
spectrum present with co-occurring (comorbid) psychiatric conditions,
particularly depression and anxiety. For example, recent studies examining
psychiatric comorbidity in young adults with autism spectrum conditions found
that 70% had experienced at least one episode of major depression, 50% had
suffered from recurrent depressive episodes, and 50% met criteria for an
anxiety disorder. Unfortunately, it appears that co-occurring psychiatric
disorders and even the diagnosis of an autism spectrum condition itself often
go unrecognized among more capable adolescents and adults on the spectrum seeking
psychological or psychiatric care. Many youth and young adults report
significant difficulties accessing healthcare services, particularly
comprehensive health services. Part of the reason for this difficulty may stem
from service providers feeling ill equipped to work with individuals with
autism, particularly individuals with co-occurring mental health issues. As a
result, adolescents and adults with autism spectrum conditions have access to
significantly fewer programs than adolescents and adults with other types of
developmental disabilities. Not surprisingly then, a consistent theme for
parents of individuals with autism is the fear that their child will fall
through the cracks when transitioning from child to adult services. Similar
concerns have been voiced by the individuals on the spectrum themselves, who describe
how their needs are infrequently recognized and the programs and services
available are not designed for people with autism spectrum conditions in mind.

Conclusions

Adolescents and adults on
the autism spectrum represent a complex and underserved population. Of the
studies completed to date, findings suggest that this group of adolescents and
adults faces a multitude of psychiatric and psychosocial issues, alongside
significant challenges in accessing services. Social skills deficits for
individuals on the spectrum persist into adulthood, and adults appear to be at
an increased risk for developing depression and anxiety. Despite this, very few
studies have examined treatment approaches and interventions (pharmacological
and psychosocial) for adolescents and adults with autism spectrum conditions.
While evidence is beginning to emerge for interventions targeting this
population, including cognitive-behavioral therapy (CBT), mindfulness-based
therapy (MBT), and social skills training (SST), further large-scale studies
which compare the effectiveness of, for example, CBT or MBT versus other
treatment options (e.g., medication, counseling, etc.) are required. Likewise, there
is an immediate need for mental health clinicians who are trained to apply
these techniques. In developing interventions, programs must also consider what
adolescents and adults want. For example, adolescents and adults on the
spectrum may be more interested in interventions which focus on vocational
opportunities than interventions targeting social skills. Moreover, both
individuals and their family must be viewed as valuable contributors and fully
involved in this process. Lastly, researchers must look at issues of service
cost and efficiency when evaluating the impact of interventions.

Recommendations

1. According
to the U.S. Surgeon General, over the course of a year, approximately 20% of
children and adolescents in the U.S. experience signs and symptoms of a mental
health problem. Unfortunately, most children and youth who are in need of
mental health services do not actually receive them. Psychological services should
be expanded in schools to include a major focus on the delivery of mental
health services to all students.

2. Developmental
disability agencies or agencies supporting individuals with autism spectrum
conditions must partner with community mental health agencies to help train,
mentor, and build capacity to care for this group across the lifespan. It is
important to note that many clinicians working within community mental health
agencies already have the skills to effectively deliver this care, but programs
either preclude their ability to do so or they lack the confidence to work with
this population.

2. There is a critical
need for community mental health agencies to review their exclusion criteria to
include persons with autism spectrum conditions. For example, agencies
providing care for persons with mood or anxiety disorders should not exclude
individuals on the basis of a diagnosis of autism. Community mental health
agencies have the resources and expertise in mental health, along with the programs
to deliver services for individuals with mental health issues (e.g., vocational
programs, counseling, and therapies), but will need guidance from developmental
disability agencies to successfully adapt these programs for adults on the
autism spectrum.

3. Developmental
disability agencies must reevaluate their inclusion criteria to include persons
with autism spectrum conditions, regardless of IQ, and across the lifespan.
Organizations must work together, combining expertise in autism from
developmental disability agencies with knowledge and resources from community
mental health agencies.

4. There is a need to
study and identify programs and supports that are most effective in both school
and community settings. This will require a full continuum of mental health
services including counseling, vocational training, supported employment, inpatient
services, and outpatient services. It will also require a network of
experienced clinicians and community partners. Many of these efforts are
already underway in pediatric settings; however, these same efforts are
required in adolescent and adult mental health services.

5. Finally, there is a
need to prepare and equip older youth with autism spectrum conditions for the
transition to adult services.

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